What do race and ethnicity mean?

The terms “race” and “ethnicity” can both be used to refer to people of similar cultural, religious, tribal, or geographic ancestry, yet they are both notoriously difficult to define. Scientists have called for using other forms of classification that are more strongly based in biology. Despite these troubled terms, health disparities exist along the blurry lines of “racial” or “ethnic” groups.

How do doctors classify racial or ethnic groups?

One of the difficulties of tracking health differences by race is that racial groups are defined in many different ways. The American Heart Association defines Latinos and Hispanics as persons who trace their ancestry to Spain, the Spanish-speaking countries of Central or South America, the Dominican Republic, or other Spanish-speaking cultures. It does not include people from Brazil, Guyana, Suriname, Trinidad, Belize, and Portugal. Many American studies limit their Hispanic population to Mexican Americans.

White or Caucasian people are considered to be those of European descent but often there is no distinction made between Eastern and Western European descent. The term “Asian” may or may not incorporate those in Southeast Asia, the Pacific Islands, and those in Western Asian and the Middle East. South Asian is sometimes used to refer to people from India, Pakistan, or Bangladesh.

The government recommends using, at a minimum, the following classification system for race:

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Should I tell my doctor about my racial or ethnic background?

Yes. Telling your doctor about your racial and ethnic background will help him or her better estimate your heart disease risk. Visual clues such as facial features or skin color have only a slim correlation with our race, so it is more helpful to tell your doctor where your ancestors are from than to have the doctor guess if you belong to some broad category such as black, white, or Asian. It is also important to let your doctor know how long you and your family have been living in the US because where you live now can sometimes reveal more about your health risks than your racial or ethnic background. For example, a study of Japanese and Japanese Americans living in Hawaii found that Japanese Americans had higher total cholesterol, a greater incidence of diabetes, and had more fatty plaque in their arteries than their counterparts still living in Japan.

How can race or ethnicity influence my heart health?

Your Race & Ethnicity Can affect your health in two main ways:

Environment

Race and ethnicity can have an influence on a person’s environment, which includes many factors such as education level, access to healthcare, cultural practices, socioeconomic status, and stress level. Race is often closely related to a person’s socioeconomic status or how much money they make. Lower socioeconomic status is associated with an increase of chronic stress, which may lead to heart problems. 10 Lower socioeconomic status is also linked to a diet high in saturated fat, cholesterol, and carbohydrates,11 as well as to poorer healthcare and health insurance.

Awareness of heart disease is lower in minority populations. In an all-women 2003 study, less than one third of African-American and Hispanic women correctly cited heart disease as the leading cause of death among women compared with more than half of white women surveyed. This survey also showed that black women, in particular, were less aware that smoking, high cholesterol, and family history increased their risk of heart disease. Some studies suggest that these social and economic factors are responsible for all of the racial/ethnic health differences or disparities.

Genetics

The second way that race and ethnicity can affect your heart health is through your genes. People of similar geographic ancestry share similar mutations in their genes. Some of these genetic variations have been linked to a higher risk of heart disease, but there are no routinely used genetic tests to see if a person carries one of these mutations. There is also no evidence that a person should receive different medical care because of their race. A report released by the Institute of Medicine that reviewed well over 100 studies on health disparities including heart disease, found that even after considering social and economic factors, racial and ethnic disparities remained. This study concluded that biases and prejudices among healthcare providers may be causing these disparities. However, some scientists believe that there may be a biological reason for health disparities.

How common is heart disease in different racial or ethnic groups?

Diseases of the heart and stroke are the leading cause of death in every ethnic group studied (white, black, Asian, Hispanic, and Native American) in the US. Death from heart disease or stroke at all ages is highest in African Americans. Black women are one third more likely to die from heart disease or stroke than white women.

In 2001, early deaths (younger than 65 years) from heart disease were most common in Native American and Alaskan Native (36%) and African Americans (32%). They were lowest among whites (15%). In a study of more than 2,600 women, black women had a 52% higher risk of heart disease than white women after ruling out many other possible explanations such as weight, blood pressure, and smoking.

Hospitalization rates for heart disease vary between Asian people of different geographic ancestry. When compared with white people, Chinese people are less likely to be hospitalized with heart disease, Japanese and Filipinos are as likely, and South Asians (Indian) are more likely.

There are racial and ethnic differences in heart disease and stroke as well.

Race, Ethnicity and Heart Disease Risk Factors

Race & Heart Disease Deaths (per 100,000 People) in 2005*

Men

Women

White

221

131

African American

251

170

Men & Women Combined

Overall Population

171

Native American/Alaskan

124

Asian/Pacific Islander

116

Hispanic

139

*For people 18 years or older

Are heart disease risk factors more common in certain racial or ethnic groups?

Yes. Black and Mexican-American women are more likely to have risk factors for heart disease than white women of similar socioeconomic status. Among American Indian and Alaskan Natives age 18 years or older, 61.4% of women have one or more risk factors such as high blood pressure, smoking, high cholesterol, obesity, or diabetes.

High blood pressure

The rate of high blood pressure in African Americans is among the highest in the world. Compared with white people, African Americans develop high blood pressure earlier in life and have much higher average blood pressure. High blood pressure appears to take a greater toll on the health of black women than white women. Black women are much more likely to visit the doctor for high blood pressure than white women. In 2003, the overall death rate from high blood pressure was nearly 3 times higher for black women than it was for white women.17 About 20% of all deaths in black women with high blood pressure may be related to their condition. Among Mexican Americans age 20 and older, about 29% of women have high blood pressure compared to 31% of white women.

Smoking

The rate of smoking and smokeless (chewing) tobacco use is highest among Native Americans and Alaskan Natives, and is higher in the South and in rural areas. About 37% of American Indian and Alaskan Native women smoke compared to 21% of white women. Within the Asian-American population, smoking rates are higher among men than women, but these rates also vary depending upon a person’s country of origin. For example, Asian-American girls age 12 to 17 years old from Vietnam, Korea, and the Philippines are more likely to be smokers than their counterparts from China and India. Among the Hispanic community, Puerto Rican women are more likely to be smokers than women from Mexico, South or Central America, or Cuba (27% vs. 16%, 17%, and 18%, respectively).

High Cholesterol

A study comparing South Asian (mainly Indian) women to white women found that South Asian women have higher rates of heart disease (4.2% vs. 1%) and they have a higher total cholesterol than their white counterparts. However, levels of LDL (bad) cholesterol levels and triglycerides – another type of blood fat that can increase the risk of heart disease – were similar in both groups. In general, white women are more likely to be diagnosed with high cholesterol than African-American or Mexican-American women.

Physical Inactivity and Obesity

In the US, Hispanics get the least amount of exercise in their spare time compared with other races/ethnicities. About 40% of Hispanic women, 32% of American and Alaskan Native women, 24% of Asian women, and 34% of African American women do not exercise, compared to 22% of white women. Women whose primary language is Spanish report no physical activity more often than people from other races (58% vs. 27%).

Income may also play a role in who does or does not exercise. Adults whose income was 4 times or more above the poverty line were twice as likely to engage in regular physical activity as those with incomes below the poverty line. This difference may be due to the financial constraints of exercising, such as gym membership or money for a babysitter.

In the US, African Americans have the highest rates of overweight and obesity compared with other races and ethnicities. About 77% of African-American women, 72% of Mexican-American women, and 61% of Native American and Alaskan Native women are overweight or obese, compared with 57% of white women.

Diabetes

Diabetes is much more common among African Americans and Hispanics than it is among whites. Diabetes rates are higher among African-American women than men at every age, but the same is not true for whites and Hispanics. Nearly 1 out of every 4 African-American women aged 65 to 74 has diabetes. The death rates for people with diabetes are 58% higher for African-American women compared with white women.

One study showed that Hispanics were twice as likely as non-Hispanics of similar age to have diabetes, but the difference was lowest in Florida and highest in California, Texas, and Puerto Rico. This may be because diabetes rates are somewhat lower in Cubans than in Mexican Americans or Puerto Ricans. Even so, all of these groups had higher rates of the disease than white Americans.

Native Americans have more than twice the risk of developing diabetes than non-Hispanic whites of similar age. Native Hawaiians are 2 ½ times more likely to have diabetes than non-Hispanic whites of similar age.

Metabolic Syndrome

Metabolic syndrome is a clustering of certain risk factors—such as higher than normal blood pressure or blood sugar levels, and a large waistline—in an individual. African-American women have about a 57% higher prevalence of metabolic syndrome than African-American men; Mexican-American women have a 26% higher prevalence than men. Overall, Hispanic women have a higher rate of metabolic syndrome than white women and African-American women have a lower rate.

Are people treated differently because of their race or ethnicity?

Yes. Except in rare cases, everyone should receive the same therapies for preventing and treating heart disease regardless of their race or ethnicity. Unfortunately, minority groups do tend to receive poorer cardiac care. In one study of more than 38,000 white and over 5,500 black patients who had had a heart attack, black patients were less likely to receive therapies like statin drugs to lower cholesterol. They were also less likely to receive treatments such as balloon angioplasty to unblock arteries, stents to prop open unblocked arteries, bypass surgery, or advice on how to quit smoking.

In an all-female study, African-American women were less likely to receive appropriate preventive care, such as aspirin or cholesterol-lowering statin medications (e.g., Lipitor). They also didn’t receive treatment or counseling on how to get their risk factors such as weight or smoking under control despite having a greater risk of a heart attack.

In one study of 700,000 elderly Medicare beneficiaries with heart disease, African Americans and Native Americans underwent invasive diagnostic and surgical procedures far less often than whites, and Asian Americans were 50% less likely to be admitted to a hospital than whites. Several studies of heart attack patients have shown that African Americans, Asian Americans, and Hispanics are less likely than whites to undergo procedures to unclog their arteries.

Does race and ethnicity affect how quickly a person gets treated?

Yes. Minority patients often wait longer for treatment. A 2004 study found significant racial differences in the time between arriving at the hospital and receiving treatment to unblock clogged arteries. For clot-busting drugs, African-American patients waited an average of 41 minutes, Asians/Pacific Islanders waited 37 minutes, and Hispanics waited 36 minutes compared with whites, who waited 34 minutes.

Are there racial and ethnic differences at different treatment centers?

Yes. Several studies have shown that the hospital itself accounts for a significant proportion of health disparities. One study showed that black patients were consistently treated at poorer-quality facilities than white patients. Black patients were more likely to undergo bypass surgery at hospitals with the highest mortality rates and at hospitals that had less experience performing the procedure. 42

What is race-based medicine?

The idea for race-based medicine comes from the observation that some medications may not work the same way in different racial or ethnic groups. These differences may be due to genetic factors that affect both how the drugs are processed in the body and the nature of a person’s heart disease.

The heart failure drug BiDil recently became the first drug specifically designated by the FDA for use in a single racial or ethnic group (African Americans), though this decision is controversial. Some scientists believe that the studies on BiDil did not do an effective comparison of the drug’s effects in different racial groups. Your ancestry should never be the only reason for a particular treatment. You should never be denied treatment on the basis of your race or ethnicity.

While racial and ethnic disparities still exist, deaths from heart disease and stroke are decreasing in all races. It is clear that when evidence-based treatments are given equally to all people, many of the health disparities disappear.